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class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 class=\u0022contributors\u0022\u003E\u003Col class=\u0022contributor-list\u0022 id=\u0022contrib-group-1\u0022\u003E\u003Cli class=\u0022contributor\u0022 id=\u0022contrib-1\u0022\u003E\u003Cspan class=\u0022name\u0022\u003ERoss D Weale\u003C\/span\u003E\u003Ca id=\u0022xref-aff-1-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-1\u0022\u003E1\u003C\/a\u003E, \u003C\/li\u003E\u003Cli class=\u0022contributor\u0022 id=\u0022contrib-2\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EV Y Kong\u003C\/span\u003E\u003Ca id=\u0022xref-aff-2-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-2\u0022\u003E2\u003C\/a\u003E, \u003C\/li\u003E\u003Cli class=\u0022contributor\u0022 id=\u0022contrib-3\u0022\u003E\u003Cspan 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class=\u0022institution\u0022\u003E256 Field Hospital\u003C\/span\u003E, \u003Cspan class=\u0022addr-line\u0022\u003ELondon\u003C\/span\u003E, UK\n\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-2\u0022 name=\u0022aff-2\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\n\u003Csup\u003E2\u003C\/sup\u003E\n\u003Cspan class=\u0022institution\u0022\u003EDepartment of Surgery\u003C\/span\u003E, \u003Cspan class=\u0022institution\u0022\u003EPietermaritzburg Metropolitan Trauma Service\u003C\/span\u003E, \u003Cspan class=\u0022addr-line\u0022\u003EDurban\u003C\/span\u003E, South Africa\n\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-3\u0022 name=\u0022aff-3\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\n\u003Csup\u003E3\u003C\/sup\u003E\n\u003Cspan class=\u0022institution\u0022\u003EDepartment of Epidemiology\u003C\/span\u003E, \u003Cspan class=\u0022institution\u0022\u003EMRC Unit, University College London\u003C\/span\u003E, \u003Cspan class=\u0022addr-line\u0022\u003ELondon\u003C\/span\u003E, United Kingdom\n\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-4\u0022 name=\u0022aff-4\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\n\u003Csup\u003E4\u003C\/sup\u003E\n\u003Cspan class=\u0022institution\u0022\u003EDepartment of Surgery\u003C\/span\u003E, \u003Cspan class=\u0022institution\u0022\u003EUniversity of the Witwatersrand\u003C\/span\u003E, \u003Cspan class=\u0022addr-line\u0022\u003EJohannesburg\u003C\/span\u003E, South Africa\n\u003C\/address\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022corresp-list\u0022\u003E\u003Cli class=\u0022corresp\u0022 id=\u0022corresp-1\u0022\u003E\u003Cspan class=\u0022corresp-label\u0022\u003ECorrespondence to\u003C\/span\u003E\n Captain\u00a0Ross D\u00a0Weale, 256 Field Hospital, London SE17 3RF, UK; \u003Cspan class=\u0022em-link\u0022\u003E\u003Cspan class=\u0022em-addr\u0022\u003Erossweale{at}doctors.org.uk\u003C\/span\u003E\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article abstract-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003EAbstract\u003C\/h2\u003E\u003Cdiv id=\u0022sec-1\u0022 class=\u0022subsection\u0022\u003E\u003Cp id=\u0022p-1\u0022\u003E\u003Cstrong\u003EIntroduction\u003C\/strong\u003E The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-2\u0022 class=\u0022subsection\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003E\u003Cstrong\u003EMethods\u003C\/strong\u003E All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-3\u0022 class=\u0022subsection\u0022\u003E\u003Cp id=\u0022p-3\u0022\u003E\u003Cstrong\u003EResults\u003C\/strong\u003E A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453\/562). A great proportion of trauma victims were male (503\/562, 90%), with a mean age of 29.5\u00b110.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28\u00b10.15) with a raised lactate (5.25\u2009mmol\/L\u00b13.71). Our primary repair rates for enteric injuries were surprisingly high.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-4\u0022 class=\u0022subsection\u0022\u003E\u003Cp id=\u0022p-4\u0022\u003E\u003Cstrong\u003EConclusion\u003C\/strong\u003E Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.\u003C\/p\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Etrauma management\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edamage control\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Elaparotomy\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/jramc.bmj.com\/content\/164\/6\/428.full\u0022 class=\u0022hw-link hw-link-article-full-text\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Full Text\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-dfp-pane oas-ads oas-ads-mid pull-right\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv id=\u0022dfp-ad-mpu-wrapper\u0022 class=\u0022dfp-tag-wrapper\u0022\u003E\n\n\u003Cdiv id=\u0022dfp-ad-mpu\u0022 class=\u0022dfp-tag-wrapper\u0022\u003E\n \u003Cscript type=\u0022text\/javascript\u0022\u003E\n googletag.cmd.push(function() {\n googletag.display(\u0022dfp-ad-mpu\u0022);\n });\n \u003C\/script\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-custom pane-1\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cp\u003E\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1136\/jramc-2018-000950\u0022 target=\u0022_new\u0022\u003Ehttp:\/\/dx.doi.org\/10.1136\/jramc-2018-000950\u003C\/a\u003E\u003C\/p\u003E\n \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-altmetrics\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003EStatistics from Altmetric.com\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv data-badge-details=\u0022right\u0022 data-badge-type=\u0022medium-donut\u0022 data-doi=\u002210.1136\/jramc-2018-000950\u0022 data-hide-no-mentions=\u0022true\u0022 class=\u0022altmetric-embed\u0022\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-bmjj-jumplinks\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-list-wrapper\u0022\u003E\u003Cdiv class=\u0022highwire-list\u0022\u003E\u003Cul\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/trauma-management\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-trauma-management\u0022 rel=\u0022nofollow\u0022\u003Etrauma management\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/damage-control\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-damage-control\u0022 rel=\u0022nofollow\u0022\u003Edamage control\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/laparotomy\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-laparotomy\u0022 rel=\u0022nofollow\u0022\u003Elaparotomy\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-1\u0022\u003E\u003Ch3\u003EKey messages\u003C\/h3\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-5\u0022\u003EThe damage control surgery (DCS)\u00a0patient demonstrates physiological derangement. A significant proportion (81%) were injuries secondary to penetrating trauma.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-6\u0022\u003EThe decision to perform DCS must be made early and communicated appropriately to all those managing the patient.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-7\u0022\u003EThe indications for DCS still rely heavily on surgical judgement.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-8\u0022\u003EMajor colonic injuries should not be repaired. These injuries should be ligated and placed back inside the abdomen.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-9\u0022\u003EAny complex operative procedures should be avoided in favour of minimalistic, temporising measures.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section intro\u0022 id=\u0022sec-5\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EIntroduction\u003C\/h2\u003E\u003Cp id=\u0022p-10\u0022\u003EThe modern concept of damage control surgery (DCS) for trauma was first introduced three decades ago. Since then, it has become widely accepted. The principle underlying DCS is that a prolonged operation in a patient with profound physiological derangements must be avoided. Instead, an abbreviated procedure must be undertaken to control bleeding and soiling and once this has been achieved definitive repair is delayed until such a time as the patient\u2019s physiology has been restored. Despite the widespread acceptance of the use of DCS there are few series in the literature documenting the use of the technique, especially from low\/middle-income countries. This retrospective audit of a prospectively maintained database comes from a busy trauma unit in South Africa. Our objectives were to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to extract the pertinent teaching\u00a0lessons from these data. Physiological parameters, and four comprehensive scores, namely penetrating abdominal trauma index\u00a0(PATI), injury severity score\u00a0(ISS), abbreviated injury scale\u00a0(AIS)-abdomen and AIS-chest, were used to assess this benchmark. The spectrum of solid organ injuries is also presented.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section methods\u0022 id=\u0022sec-6\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EMethods\u003C\/h2\u003E\u003Cdiv id=\u0022sec-7\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EClinical setting\u003C\/h3\u003E\u003Cp id=\u0022p-11\u0022\u003EKwaZulu-Natal (KZN)\u00a0province is located on the east coast of South Africa and has a population of over 11\u2009million people. Fifty per\u00a0cent of the population resides in the rural areas. The city of Pietermaritzburg is the largest city in the interior of the province and has a population of 1 million people. The Pietermaritzburg Metropolitan Trauma Service (PMTS) provides trauma care to the city of Pietermaritzburg, KZN\u00a0province, South Africa, as well as to the predominantly rural western third of the province, KZN. It also serves as the referral centre for 19 other rural hospitals within the western third of the province, and has a total catchment population of over 3 million people. All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry. The PMTS maintains a prospectively entered electronic surgical registry known as the Hybrid Electronic Medical Registry (HEMR), which commences in December 2012. All surgical patients are captured on this system.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-8\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EParticipants\u003C\/h3\u003E\u003Cp id=\u0022p-12\u0022\u003EThe details of all patients over the age of 15 who required a laparotomy for trauma between December 2012 and\u00a0July 2016 were retrieved from the HEMR. All those who required a DCS were then selected out for more in-depth analysis. Once these two groups had been broadly defined they were compared in terms of their physiology and outcome. The DCS cohort was then analysed in more detail.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-9\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EVariables\u003C\/h3\u003E\u003Cp id=\u0022p-13\u0022\u003EPhysiological parameters were assessed including: systolic BP\u00a0(SBP), diastolic BP\u00a0(DBP), HR, RR, SpO\u003Csub\u003E2\u003C\/sub\u003E, pH, pO\u003Csub\u003E2\u003C\/sub\u003E (kPa), pCO\u003Csub\u003E2\u003C\/sub\u003E (kPa), base excess (BE, mEq\/L) and HCO\u003Csub\u003E3\u003C\/sub\u003E (mEq\/L). Visceral injuries assessed included: small bowel\u00a0(SB), liver,\u00a0large bowel\u00a0(LB), diaphragm, intra-abdominal vascular injury\u00a0(IAVI), stomach, spleen, pancreas, kidney\u00a0and duodenum. Injury mechanism was divided into blunt versus penetrating, and penetrating was then further subdivided into gunshot wound\u00a0(GSW) versus stab wound\u00a0(SW). A calculation of four comprehensive scores was performed, including PATI, ISS, AIS-abdomen and AIS-chest.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-10\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EStatistical analysis\u003C\/h3\u003E\u003Cp id=\u0022p-14\u0022\u003EStatistical analysis was performed using STATA V.15.0\u00a9. Physiological parameters were assessed using unpaired t-test, and categorical variables assessed with \u03a7\u003Csup\u003E2\u003C\/sup\u003E test.\u003C\/p\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section results\u0022 id=\u0022sec-11\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EResults\u003C\/h2\u003E\u003Cp id=\u0022p-15\u0022\u003EA total of 562 patients underwent trauma laparotomy during the period under review. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453\/562). A great proportion of trauma victims were male (503\/562, 90%), with a mean age of 29.5\u00b110.8.\u003C\/p\u003E\u003Cdiv id=\u0022sec-12\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EPresenting physiology and time\u003C\/h3\u003E\u003Cp id=\u0022p-16\u0022\u003EA comparison of presenting physiological parameters for DCS versus non-DCS procedures was made (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003Etable 1\u003C\/a\u003E). Those with DCS has higher lactate, HR, RR, as well as lower SBP, DBP, SpO\u003Csub\u003E2\u003C\/sub\u003E, pH, BE and HCO\u003Csub\u003E3\u003C\/sub\u003E (all p\u0026lt;0.001). There was no difference in pO\u003Csub\u003E2\u003C\/sub\u003E (p=0.895) or pCO\u003Csub\u003E2\u003C\/sub\u003E (p=0.182) between groups. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p\u0026lt;0.001). The mean time of a damage control procedure was 97\u2009min (\u00b152) vs 101\u2009min (\u00b148) for non-DCS (p=0.529).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/153850\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/153850\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1\u003C\/span\u003E \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003EPresenting demographics and physiology for DCS versus non-DCS cases\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-13\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EThe DCS cohort\u003C\/h3\u003E\u003Cp id=\u0022p-21\u0022\u003EOut of the 99 patients who underwent DCS, there were 32 mortalities (32%). The mean age was 33.6 years (\u00b112.3). The majority of cases were male (n=84, 85%) versus female (n=15, 15%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28\u00b10.15) with a raised lactate (5.25\u2009mmol\/L\u00b13.71). The majority of cases (71, 72%) were for penetrating trauma, of which the majority (n=46, 65%) were secondary to GSW. The most common organ injury was to the SB, n=49 (49%), with the least common being the kidney and duodenum, both n=12 (12%). Demographic data are displayed in \u003Ca id=\u0022xref-table-wrap-1-2\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003Etable 1\u003C\/a\u003E.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-14\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EImpact of mechanism\u003C\/h3\u003E\u003Cp id=\u0022p-22\u0022\u003E\n\u003Ca id=\u0022xref-table-wrap-group-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#table-wrap-group-1\u0022\u003ETable 2\u003C\/a\u003E compares the different organs injured between blunt and penetrating mechanisms. Penetrating injuries had significantly higher rates of the following injuries compared with blunt: LB\u00a0(41% vs 11%, p=0.04), diaphragm (30% vs 7%, p=0.017), IAVI (28% vs 7%, p=0.023) and duodenal (75% vs 25%, p=0.001). For the penetrating subgroup, GSW had significantly higher rates of the following injuries compared with SW: liver (41% vs 20%, p=0.070), LB (50% vs 24%, p=0.033), diaphragm (39% vs 12%, p=0.017) and stomach (40% vs 12%, p=0.026).\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/153851\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/153851\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2\u003C\/span\u003E \u003Cp id=\u0022p-23\u0022 class=\u0022first-child\u0022\u003EComparison of organ injury and mechanism in DCS versus non-DCS cases\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv id=\u0022T3\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/153837\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/153837\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-15\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003ESpectrum of injuries\u003C\/h3\u003E\u003Cp id=\u0022p-27\u0022\u003EThe total number of abdominal organ injuries was counted for each case. These included injuries to the SB, liver, LB, diaphragm, IAVI, stomach, spleen, pancreas, kidney\u00a0and duodenum. The numbers of organs injured were divided into subgroups of\u00a0\u22641, 2\u20133\u00a0and\u00a04+. Penetrating injuries had a significantly higher number of 4+\u00a0injuries compared with blunt (23% vs 4%) (\u003Ca id=\u0022xref-table-wrap-4-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T4\u0022\u003ETable 3A\u003C\/a\u003E). Within the penetrating subgroup, GSW had the greatest frequency of multiple organ injuries compared with SW (33% vs 4% involving 4+\u00a0organs) (\u003Ca id=\u0022xref-table-wrap-4-2\u0022 class=\u0022xref-table\u0022 href=\u0022#T4\u0022\u003ETable 3B\u003C\/a\u003E). The mean scores for DCS versus non-DCS were as follows: PATI 17.4 (\u00b113.2) vs 13.6 (\u00b110.4), p=0.058; ISS 13.8 (\u00b18.2) vs 12.5 (\u00b18.0), p=0.208; AIS-abdomen 3.3 (\u00b10.8) vs 3.0 (\u00b11.0), p=0.045; AIS-chest 0.67 (\u00b11.2) vs 0.56 (\u00b11.1), p=0.431 (\u003Ca id=\u0022xref-table-wrap-group-1-2\u0022 class=\u0022xref-table\u0022 href=\u0022#table-wrap-group-1\u0022\u003Etable 2\u003C\/a\u003E).\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-16\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003EManagement of injuries\u003C\/h3\u003E\u003Cp id=\u0022p-28\u0022\u003EA total of 15 liver injuries were packed; in two cases the liver injuries were simply drained and in one case each the liver was sutured or a necrotic segment debrided. A total of 25 SB injuries were repaired, 22 were ligated and 25 repaired, and 27 underwent a resection and anastomosis. Of the SB injuries repaired, the American Association for the Surgery of Trauma (AAST) grade ranged from 2 to 5. A total of 20 large bowel injuries were ligated, and 10 underwent primary repair and 2 primary diversion. The AAST grades of those repaired were: grade 1\u00a0(3), grade 2\u00a0(2), grade 3\u00a0(3) and grade 4\u00a0(1).\u00a0In seven cases, a renal injury was dealt with by nephrectomy and in five cases the perirenal haematoma was simply not explored. Four IAVIs were repaired. These included injuries to the external iliac vein and artery, the aorta, and two inferior vena cava injuries. A total of 15 vascular injuries were ligated. These included the following injuries: LB mesentery (3), right gastroepiploic artery\u00a0(1), middle colic artery\u00a0(1), sacral venous plexus\u00a0(1), right external iliac vein\u00a0(1), pancreaticoduodenal vein\u00a0(1), splenic artery\u00a0(1), superior mesenteric vein and inferior mesenteric artery\u00a0(1), left external iliac vein (1), SB mesentery (1), left common iliac vein\u00a0(1), sigmoid artery and vein\u00a0(1), and\u00a0left renal vein\u00a0(1). Two vascular injuries to the liver were managed by packing alone. Primary closure or the abdomen was performed in 26 cases, and temporary abdominal closure in 73 patients.\u003C\/p\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section discussion\u0022 id=\u0022sec-17\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EDiscussion\u003C\/h2\u003E\u003Cp id=\u0022p-29\u0022\u003EDCS is derived from the US Navy, and refers to the emergency measures needed to keep a ship afloat until definitive repairs can be undertaken. It has a long prehistory and in 1908, the Australian-born Scottish surgeon James Pringle described the packing of liver injuries.\u003Ca id=\u0022xref-ref-3-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-3\u0022\u003E3\u003C\/a\u003E Modern DCS was described by Rotondo \u003Cem\u003Eet\u00a0al\u003C\/em\u003E in 1993.\u003Ca id=\u0022xref-ref-2-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2\u003C\/a\u003E They demonstrated a significant survival benefit in DCS compared with definitive laparotomy for patients with severe trauma.\u003C\/p\u003E\u003Cp id=\u0022p-30\u0022\u003EHowever, the indications for DCS still rely heavily on surgical judgement and in this cohort of compromised patients, the margin for error is extremely small and poor decision-making can have significant negative sequela. Most trauma surgeons emphasise that both anatomic and physiological factors must be considered when deciding to adopt a DCS approach. These criteria include an arterial pH\u00a0\u0026lt;7.2, SBP persistently \u0026lt;90\u2009mm Hg, as well as injuries to the pancreatic-duodenal complex and to the liver.\u003Ca id=\u0022xref-ref-1-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-1\u0022\u003E1\u003C\/a\u003E Our cohort demonstrated physiological compromise as evidenced by the elevated mean lactate at 5.75 (\u00b13.71) and mean BE of \u22127.14 (\u00b10.72) (\u003Ca id=\u0022xref-table-wrap-1-3\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). The mechanism of trauma also appears to be very predictive of the need for DCS with the well over two-thirds of the patients requiring DCS having sustained (72%) penetrating torso trauma, which is associated with a greater number of intra-abdominal injuries than blunt trauma (\u003Ca id=\u0022xref-table-wrap-4-3\u0022 class=\u0022xref-table\u0022 href=\u0022#T4\u0022\u003ETable 3A\u003C\/a\u003E). In the penetrating cohort, GSWs are more likely to require DCS than SWs as reflected by the increased number of intra-abdominal injuries associated with GSW to the abdomen (SW) (\u003Ca id=\u0022xref-table-wrap-4-4\u0022 class=\u0022xref-table\u0022 href=\u0022#T4\u0022\u003Etable 3B\u003C\/a\u003E). A third of GSW injuries presented with injuries to more than four intra-abdominal structures.\u003C\/p\u003E\u003Cdiv id=\u0022T4\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/153840\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/153840\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 3\u003C\/span\u003E \u003Cp id=\u0022p-31\u0022 class=\u0022first-child\u0022\u003E(A)The number of organs injured compared between blunt and penetrating mechanisms for all 99 DCS\u00a0cases. (B)The number of organs injured compared between GSW and SW\u00a0mechanisms for all 71 penetrating DCS\u00a0cases\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-33\u0022\u003EDCS techniques eschew complex operative procedures in favour of minimalistic and temporising procedures. Reviewing the techniques used in this cohort suggests that the principles of DCS are being applied incompletely. Packing of liver injuries is now widely accepted and was the most common management of liver injuries in our setting. Non-expanding perirenal haematomas can be safely left unexplored in the acute setting, if exploration is undertaken then it is highly likely that a nephrectomy will be necessary. For these solid organs it would appear that our staff are well versed in DCS and tend to apply the approach appropriately to these injuries. The management of visceral injuries in this cohort however suggests that decision-making for these injuries is more opaque. Major colonic injuries should not be repaired primarily, neither should they undergo primary diversion. The role of primary diversion of colonic injuries during the initial operation should be extremely limited. If the patient cannot withstand a primary repair, then the injury should be ligated and placed back inside the abdomen. The high rates of primary repair of SB and colonic injuries during DCS suggest that the decision to opt for a DCS procedure is not being made timeously enough and that surgeons are tending to use DCS as a bailout option. The fact that\u00a0the operative length between DCS and non-DCS procedures was not significantly different is reflective of this. With vascular injuries staff are more likely to adopt a DCS approach and almost all non-essential major vessels (15) were simply ligated. The four vessels which were repaired were major vessels and external iliac vein and artery in one case, aorta, and two\u00a0Inferior vena cava\u00a0 (IVC) injuries. Patients who undergo DCS should have their abdomen left open to prevent the development of intra-abdominal hypertension. However, this was only performed in 73% of cases, once again suggesting deficits in the understanding of DCS among our staff.\u003C\/p\u003E\u003Cp id=\u0022p-34\u0022\u003EOur data are similar to that reported from major international series as shown in \u003Ca id=\u0022xref-table-wrap-5-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T5\u0022\u003Etable 4\u003C\/a\u003E. Both the demographics and the presenting physiology appear to be similar.\u003Ca id=\u0022xref-ref-2-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2 4 5\u003C\/a\u003E There is no significant variation in survivability in our study (2012\u20132017) (68%) versus the Pakistani group\u003Ca id=\u0022xref-ref-5-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-5\u0022\u003E5\u003C\/a\u003E\u00a0(1996\u20132011) (55%) versus Rotondo \u003Cem\u003Eet al\u003C\/em\u003E (USA) (1993) (58%)\u003Ca id=\u0022xref-ref-2-3\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2\u003C\/a\u003E;\u00a0however, Johnson \u003Cem\u003Eet al\u003C\/em\u003E (1997\u20132000)\u003Ca id=\u0022xref-ref-4-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-4\u0022\u003E4\u003C\/a\u003E have survival rates of 90%. The international consensus that physiological derangement should supersede anatomic consideration is shared in Brazil\u003Ca id=\u0022xref-ref-6-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-6\u0022\u003E6\u003C\/a\u003E and India.\u003Ca id=\u0022xref-ref-7-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-7\u0022\u003E7\u003C\/a\u003E This is an important lesson as prolonged operating prior to adopting a DCS approach is not prudent. The decision to opt for DCS should be made early. One of the major limitations of this study is that the surgical decision-making process remains opaque and is almost impossible to tease out with a retrospective analysis. DCS should be a conscious decision made extremely early in the care pathway. Unfortunately, DCS is frequently used as a bailout procedure when the surgeon realises the magnitude of the derangement and suddenly beats a hasty retreat. The two situations are not analogous. Our data suggest that there is an incomplete understanding of the principles of DCS even in a high-volume centre such as ours. DCS techniques seem to well applied to solid visceral and vascular injuries, however they are applied inconsistently to SB and colonic injuries. In addition, there appears to be incomplete understanding about the optimal approach to managing the abdominal wound in these patients with critical injury.\u003C\/p\u003E\u003Cdiv id=\u0022T5\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/153802\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/153802\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 4\u003C\/span\u003E \u003Cp id=\u0022p-35\u0022 class=\u0022first-child\u0022\u003EAn international comparison of the demographics, physiology and outcome of DCS laparotomy\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-18\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003ELessons learnt\u003C\/h3\u003E\u003Cp id=\u0022p-38\u0022\u003EDamage control is a minimalistic, truncated procedure. The fact that\u00a0the length of procedure across DCS and non-DCS groups in this series was not significantly different is reflective of an incomplete understanding of the principles of DCS and this is especially apparent in the management of SB and colonic injuries and of the abdominal incision.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv id=\u0022sec-19\u0022 class=\u0022subsection\u0022\u003E\u003Ch3\u003ERelevance to the Medical Officer\u003C\/h3\u003E\u003Cp id=\u0022p-39\u0022\u003EThe arena of warfare is changing. Enduring operations such as those in Afghanistan commonly saw casualties bypass the Role 1 treatment facility and head straight for the Role 2 enhanced facility at Camp Bastion. As operations become less enduring, without the support of a nearby Role 2 facility, the Medical Officer at a Role 1 will become more integral in providing damage control resuscitation, and damage control procedures should form the very foundation of a military surgeon\u2019s skill\u00a0set.\u003C\/p\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section conclusions\u0022 id=\u0022sec-20\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EConclusion\u003C\/h2\u003E\u003Cp id=\u0022p-40\u0022\u003EJust under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient. Although DCS approaches are applied appropriately to solid organ and vascular injuries, the same cannot be said for the management of enteric injuries and of the abdominal incision. Further refinement of our algorithms is necessary to assist with surgical decision-making in these patients.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EReferences\u003C\/h2\u003E\u003Col class=\u0022cit-list\u0022\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-1-1\u0022 title=\u0022View reference 1 in text\u0022 id=\u0022ref-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ERoberts\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EDJ\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EZygun\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EDA\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EFaris\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EPD\u003C\/span\u003E\n\u003C\/span\u003E, \u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EOpinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJ Am Coll Surg\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2016\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E223\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E515\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E29\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1016\/j.jamcollsurg.2016.06.002\u0022\u003Edoi:10.1016\/j.jamcollsurg.2016.06.002\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DJ%2BAm%2BColl%2BSurg%26rft.volume%253D223%26rft.spage%253D515%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-2-1\u0022 title=\u0022View reference 2 in text\u0022 id=\u0022ref-2\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.2\u0022 data-doi=\u002210.1097\/00005373-199309000-00008\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ERotondo\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMF\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ESchwab\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ECW\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EMcGonigal\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMD\u003C\/span\u003E\n\u003C\/span\u003E, \u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003E\u2019Damage control\u0027: an approach for improved survival in exsanguinating penetrating abdominal injury\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJ Trauma\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E1993\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E35\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E375\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E82\u003C\/span\u003E. \u003Cspan class=\u0022cit-comment\u0022\u003Ediscussion 382-3.\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DThe%2BJournal%2Bof%2Btrauma%26rft.stitle%253DJ%2BTrauma%26rft.aulast%253DRotondo%26rft.auinit1%253DM.%2BF.%26rft.volume%253D35%26rft.issue%253D3%26rft.spage%253D375%26rft.epage%253D382%26rft.atitle%253D%2527Damage%2Bcontrol%2527%253A%2Ban%2Bapproach%2Bfor%2Bimproved%2Bsurvival%2Bin%2Bexsanguinating%2Bpenetrating%2Babdominal%2Binjury.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00005373-199309000-00008%26rft_id%253Dinfo%253Apmid%252F8371295%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1097\/00005373-199309000-00008\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=8371295\u0026amp;link_type=MED\u0026amp;atom=%2Fjramc%2F164%2F6%2F428.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=A1993LY24200008\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-3-1\u0022 title=\u0022View reference 3 in text\u0022 id=\u0022ref-3\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.3\u0022 data-doi=\u002210.1097\/00000658-190810000-00005\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EPringle\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJH\u003C\/span\u003E\n\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003ENotes on the Arrest of Hepatic Hemorrhage Due to Trauma\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EAnn Surg\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E1908\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E48\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E541\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E9\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1097\/00000658-190810000-00005\u0022\u003Edoi:10.1097\/00000658-190810000-00005\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DAnnals%2Bof%2Bsurgery%26rft.stitle%253DAnn%2BSurg%26rft.aulast%253DPringle%26rft.auinit1%253DJ.%2BH.%26rft.volume%253D48%26rft.issue%253D4%26rft.spage%253D541%26rft.epage%253D549%26rft.atitle%253DV.%2BNotes%2Bon%2Bthe%2BArrest%2Bof%2BHepatic%2BHemorrhage%2BDue%2Bto%2BTrauma.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00000658-190810000-00005%26rft_id%253Dinfo%253Apmid%252F17862242%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1097\/00000658-190810000-00005\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=17862242\u0026amp;link_type=MED\u0026amp;atom=%2Fjramc%2F164%2F6%2F428.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000201621400049\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-2-2\u0022 title=\u0022View reference 4 in text\u0022 id=\u0022ref-4\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.4\u0022 data-doi=\u002210.1097\/00005373-200108000-00007\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EJohnson\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJW\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EGracias\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EVH\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ESchwab\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ECW\u003C\/span\u003E\n\u003C\/span\u003E, \u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EEvolution in damage control for exsanguinating penetrating abdominal injury\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJ Trauma\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2001\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E51\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E261\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E71\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1097\/00005373-200108000-00007\u0022\u003Edoi:10.1097\/00005373-200108000-00007\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DThe%2BJournal%2Bof%2Btrauma%26rft.stitle%253DJ%2BTrauma%26rft.aulast%253DJohnson%26rft.auinit1%253DJ.%2BW.%26rft.volume%253D51%26rft.issue%253D2%26rft.spage%253D261%26rft.epage%253D269%26rft.atitle%253DEvolution%2Bin%2Bdamage%2Bcontrol%2Bfor%2Bexsanguinating%2Bpenetrating%2Babdominal%2Binjury.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00005373-200108000-00007%26rft_id%253Dinfo%253Apmid%252F11493783%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1097\/00005373-200108000-00007\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=11493783\u0026amp;link_type=MED\u0026amp;atom=%2Fjramc%2F164%2F6%2F428.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000170462400006\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-2-2\u0022 title=\u0022View reference 5 in text\u0022 id=\u0022ref-5\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.5\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EKisat\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EM\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EZafar\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ESN\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EHashmi\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EZG\u003C\/span\u003E\n\u003C\/span\u003E, \u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EExperience of damage control trauma laparotomy in a limited resource healthcare setting: A retrospective Cohort Study\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EInt J Surg\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2016\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E28\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E71\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E6\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1016\/j.ijsu.2016.02.042\u0022\u003Edoi:10.1016\/j.ijsu.2016.02.042\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DInt%2BJ%2BSurg%26rft.volume%253D28%26rft.spage%253D71%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-6-1\u0022 title=\u0022View reference 6 in text\u0022 id=\u0022ref-6\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.6\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EPimentel\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ESK\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ERucinski\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ET\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003EMeskau\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMPA\u003C\/span\u003E\n\u003C\/span\u003E, \u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EDamage control surgery: are we losing control over indications?\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ERev Col Bras Cir\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2018\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E45\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1590\/0100-6991e-20181474\u0022\u003Edoi:10.1590\/0100-6991e-20181474\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-7-1\u0022 title=\u0022View reference 7 in text\u0022 id=\u0022ref-7\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-164.6.428.7\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ERao\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EPP\u003C\/span\u003E\n\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\n\u003Cspan class=\u0022cit-name-surname\u0022\u003ESingh\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EDV\u003C\/span\u003E\n\u003C\/span\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003ECombat surgery: Status of tactical abbreviated surgical control\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EMed J Armed Forces India\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2017\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E73\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E407\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E9\u003C\/span\u003E.\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1016\/j.mjafi.2017.05.003\u0022\u003Edoi:10.1016\/j.mjafi.2017.05.003\u003C\/a\u003E\n\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca 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